thanks and no-thanks

Getting in four days in a row has been fun. I barely noticed when thanksgiving came and went.

Three days on the floor, two on rehab and one on long-term, and one day as supervisor.

I'm picking things up fast. After just a few weeks, all of a sudden people are asking -me- where to find forms and documents, people who've been working there way longer than I have.

The forms and documents thing has been a thorn in my side from day one. We have four drawers that have all the documents I need. Infection control reports, care plans (ugh), incident reports, lab slips, you name it. Working an admission is made more difficult than necessary by this filing system, especially when I have to break my chain of thought for 15 minutes to hunt for a piece of paper. The actual admission itself only takes me an hour or two, the rest of the time (which may be several hours) is spent trying to figure out where all of the relevant pieces of paper are and where I need to put them later (even though the HUC preloads the chart with all of the most important documents).

I'm starting to have a lot of fun with the lab orders. Now that I've gotten the hang of the labs, a whole galaxy of diagnostic possibilities is unfolding. This week I ordered some thyroid studies, basic blood-work and cancer-specific antigen tests. I mapped out all the diagnostic studies I wanted done for the next week and filed the lab slips in the appropriate sections of a voluminous three-ring binder.

I'm continuing to look critically at some of the medication orders. Some things slip through that shouldn't, in my opinion. One resident gets 3.9g of acetaminophen -scheduled- throughout the day, and still has an as-needed order for 650mg of acetaminophen. If anyone looked at that and said "hey, let's give him the PRN tylenol", they would have administered a potentially fatal overdose. Next time I'm in, me and my magical "discontinue" highlighter are goin' on a rampage. What's even more subtle and easy to miss is the combination opioid/non-opioid analgesics, some people forget which ones have tylenol and which ones have aspirin, a potentially serious mix-up.

I'm starting to take the broader view of what's going on here, and spending time in the trenches (on the floor) is directly responsible for that.

Now I'm starting to have to mitigate some of the personality conflicts on the unit, particularly among the CNAs. Managing people is tough! I'm relieved that some of the people I've asked to do labor intensive things still have a good enough rapport with me to come to -me- with their problems and not the other nurse supervisors. The reasons for this tend to revolve around fear of retribution, or even just being identified by the other CNAs as someone who "reports" things to the nurse supervisors.

I'm trying to sort out in my head how to handle these intraprofessional conflicts. It's tricky. I try to purchase all the capital I can by answering call-bells, helping with toileting and repositioning, and I think this is paying off with some people. So much goes on behind my back, however, it's difficult to know how to address some of these concerns without making it obvious who told me about them.

I have to keep up on the disciplinary process, though. If I get too lassez-faire, my shifts will be an anything-goes environments for the aides, and there's already too much of that, in my opinion. Weights don't get collected when they should, intake and output is guesstimated more than I would like, and some people have a nasty habit of forgetting to attach a tab or pad alarm to our fall-prone residents. I don't want to alienate these people I rely so heavily on, but I'm responsible for the kind of work they do.

I prefer to handle most things with a private word and a gentle reminder, but it's clear I'm going to have to leave a cogent paper-trail, for the sake of my license.

I saw my first Marinol pill today. The resident taking it didn't even know what it was or where it came from! The pills are cute. They are spherical, light green, and roll around pleasantly in the blister-packs.


Strong One said...

A tough job, a tough job indeed. You seem to be lining all your ducks appropriately.
I got exhausted just reading about all your many complex responsibilities.
Keep up the great work and great attitude!
Best of luck

Chris said...

All of the problems you are having sound the like problems charge nurses deal with on my unit, too. It sounds like you have good intuitions. Just remember, you won't reach a steady-state of productivity and good will, so don't get discouraged.